Introduction
Chronic pain is an urgent public health concern that significantly impairs the physical, psychological, and social functioning of those experiencing it and their significant others. The Institute of Medicine (IOM) recently estimated that more than 110 million adults, over one third of the population of the United States, experience some form of chronic pain, with the symptom of pain being the most common reason for people to consult a primary care physician. Despite the magnitude of this problem, pain management is severely under-represented in the content of medical education and is delivered by many providers who feel unprepared to manage it. Consequently, treatment of pain is highly variable and often unstructured, with important decisions being based primarily on clinician intuition, personal bias, and the severe time constraints present in hurried practices.
It is estimated that chronic pain costs between $565 and $635 billion per year in health care and reduced productivity; these costs have increased fivefold in the past decade and will probably increase with the aging population. However, these increases in health care expenditures have not translated into improvements in clinical outcomes. In addition, the National Center for Health Statistics noted that 40% of people reporting chronic pain indicate moderate to severe degradation in their functioning, thereby contributing to the high direct and indirect costs of chronic pain. Poor provider self-reported pain care competency reduces clinician productivity and increases practice dissatisfaction in those managing chronic pain. Most importantly, these costs do not reflect the incalculable impact of pain on the lives of patients and their significant others.
Given that chronic pain is a complex biopsychosocial disorder, successful management of it requires a systematic multidimensional approach to assessment and strategically targeted interdisciplinary therapies. Care of complex chronic illness requires defined processes for rapid identification of problems and “stepped” systems that reliably direct services to intensified treatment strategies for challenging patients who have a limited or poor response to initial treatments. This chapter discusses a patient-centered approach to the care of chronic pain and how outcomes are improved when an interspecialty collaborative model is followed.
Stepped Care
The stepped care model entails a well-established primary care response to the management of chronic disease that systematically adjusts medical treatment when patients are not responding to initial interventions. Wagner and colleagues cited five components of stepped care :
- 1.
Use of explicit plans and protocols
- 2.
Reorganization of the practice to meet the needs of patients who require more time, a broad array of resources, and closer follow-up
- 3.
Systematic attention to the information and behavioral change needs of patients
- 4.
Ready access to necessary expertise
- 5.
Supportive information systems
Von Korff and Tiemans subsequently described a model involving the stepwise introduction of targeted interventions to improve the care of patients with chronic illness; this model provides a framework for achieving cost-effective care based on patients’ observed response to treatment.
Stepped Care in Pain
The World Health Organization (WHO) cancer pain analgesic ladder is a historic example of a stepped care model, though with a sharply delineated focus on relief of the intensity of cancer pain alone ( Fig. 4.1 ).
This is undoubtedly a useful and effective model for relieving acute and progressive pain from cancer and for palliative and end-of-life care of pain when reducing the intensity of pain becomes the primary and often sole goal of treatment, even, when necessary, at the expense of function. The WHO ladder continues to be useful even though it does not include pain’s other domains of biopsychosocial distress. Care of chronic noncancer pain focuses its outcome on function—not primarily comfort— in patients not at the end of life and thus needs to incorporate other of pain’s domains beyond reported pain intensity.
John Loeser from the University of Washington has depicted the individual’s experience of chronic pain as a concentric series of domains and specifically differentiated the painful nociceptive experience from the enveloping experience of suffering and maladaptive behavior that patients with chronic pain often demonstrate. A search for the elusive nociceptive pain generator that can be numbed, burned, or otherwise removed will undoubtedly result in exclusion of care for complex pain disorders, which often require systematic multidimensional assessment of pain. Loeser’s “onion” ( Fig. 4.2 ) is a multilayered rather than a multistepped care model, and although he does not delineate algorithmic plans, protocols, and measures in detail, it still anticipates a stepped approach to the care of pain in patients with chronic illness.
Von Korff and Moore proposed a stepped care approach specifically for the primary care management of chronic back pain in which interventions are sequenced “so that the intensity, complexity, and costs of care are guided by each patient’s observed outcome.” Otis and coauthors also published a convincing case-based rationale for the stepwise integration of coordinated mental health services into progressively more treatment-resistant pain care coordinated within a primary care practice setting.
Stepped Care
The stepped care model entails a well-established primary care response to the management of chronic disease that systematically adjusts medical treatment when patients are not responding to initial interventions. Wagner and colleagues cited five components of stepped care :
- 1.
Use of explicit plans and protocols
- 2.
Reorganization of the practice to meet the needs of patients who require more time, a broad array of resources, and closer follow-up
- 3.
Systematic attention to the information and behavioral change needs of patients
- 4.
Ready access to necessary expertise
- 5.
Supportive information systems
Von Korff and Tiemans subsequently described a model involving the stepwise introduction of targeted interventions to improve the care of patients with chronic illness; this model provides a framework for achieving cost-effective care based on patients’ observed response to treatment.
Stepped Care in Pain
The World Health Organization (WHO) cancer pain analgesic ladder is a historic example of a stepped care model, though with a sharply delineated focus on relief of the intensity of cancer pain alone ( Fig. 4.1 ).
This is undoubtedly a useful and effective model for relieving acute and progressive pain from cancer and for palliative and end-of-life care of pain when reducing the intensity of pain becomes the primary and often sole goal of treatment, even, when necessary, at the expense of function. The WHO ladder continues to be useful even though it does not include pain’s other domains of biopsychosocial distress. Care of chronic noncancer pain focuses its outcome on function—not primarily comfort— in patients not at the end of life and thus needs to incorporate other of pain’s domains beyond reported pain intensity.
John Loeser from the University of Washington has depicted the individual’s experience of chronic pain as a concentric series of domains and specifically differentiated the painful nociceptive experience from the enveloping experience of suffering and maladaptive behavior that patients with chronic pain often demonstrate. A search for the elusive nociceptive pain generator that can be numbed, burned, or otherwise removed will undoubtedly result in exclusion of care for complex pain disorders, which often require systematic multidimensional assessment of pain. Loeser’s “onion” ( Fig. 4.2 ) is a multilayered rather than a multistepped care model, and although he does not delineate algorithmic plans, protocols, and measures in detail, it still anticipates a stepped approach to the care of pain in patients with chronic illness.
Von Korff and Moore proposed a stepped care approach specifically for the primary care management of chronic back pain in which interventions are sequenced “so that the intensity, complexity, and costs of care are guided by each patient’s observed outcome.” Otis and coauthors also published a convincing case-based rationale for the stepwise integration of coordinated mental health services into progressively more treatment-resistant pain care coordinated within a primary care practice setting.
Collaborative Care Approach
The most robust demonstration of the effectiveness of collaborative care has been described in the management of depression. Unützer and Park described a model of “measurement-based care, treatment to target, and stepped care in which treatments are systematically adjusted and ‘stepped up’ if patients are not improving as expected.” This approach has demonstrated improved patient satisfaction and health outcomes.
Collaborative Care of Pain
Dobscha and others described a model and the preliminary outcomes of collaborative care for chronic musculoskeletal pain in primary care practice. A clustered randomized trial that evaluated collaborative care for chronic pain in five primary care settings within a single Veterans Administration medical center demonstrated greater improvement in pain-related disability, and in patients with baseline depression, greater improvement in the severity of depression was achieved in those receiving the intervention than in patients receiving treatment as usual. The study intervention followed the stepped care approach and included patient assessment, monitoring of symptoms, a two-session program for education of clinicians, education and activation, feedback and recommendations to clinicians, and facilitation of specialty care. Outcome measures used in this study were the Roland-Morris Disability Questionnaire and the Patient Health Questionnaire 9-item (PHQ-9) depression inventory.
Existing Guidelines
Multiple guidelines and algorithms have been published for specific painful disorders, including back pain, headache, and other chronic pain conditions commonly encountered in both specialty and primary care clinical practice. Many guidelines exist for opioid management ; however, there are limited published and widely accepted clinical practice guidelines for comprehensive measurement-based, stepped care for chronic pain beyond efforts by the Department of Veterans Affairs to streamline the treatment of pain within its health care setting. This gap persists despite published evidence that such a stepped care approach leads to better overall outcomes. The following sections summarize various studies in the published literature that have evaluated the stepped care approach, as well as efforts made to date that hold promise for more standardized and widely accepted clinical practice guidelines.
Pain Care Progression Model
Dubois and colleagues proposed a pyramidal model for implementing a “population-based stepped-care approach to chronic pain” ( Fig. 4.3 ). Their future model for management of pain in the U.S. Veterans Health Administration medical system calls for increased levels of expertise based on a patient’s level of complexity. Although it does recognize that specific degrees of expertise are necessary for effective treatment outcomes, being essentially a stepped model extending up through the continuum of primary to tertiary pain care, it does not anchor these levels with measurement-based benchmarks that systematize the assessment to determine who progresses and to which type of physician or other health care professional. A proposed linkage of stepped care with a measurement-based approach is described below.
Measurement-Based Stepped Care: The Pain Treatment Domains
Because chronic pain is a multidimensional disorder, achieving the best outcomes requires attention to more domains than just self-reported pain intensity. The “fifth vital sign,” which is useful for the care of acute pain, is an insufficient assessment measure for achieving the best outcomes in patients with chronic pain. Measurement-based care directed toward physical and emotional function , quality of sleep , risk for chemical dependency , adherence to treatment , patient satisfaction , and self-reported quality of life is well recognized and in fact involves critical patient response domains that, when followed over time, permit useful assessment of outcomes. Adjusting pain treatment on the basis of immediate clinical outcomes follows the fundamental tenet of “stepped care.” Just as a random blood sugar measurement is not a sufficient measure of care in a diabetic patient, chronic pain in a complex chronic illness such as diabetes requires measurement and tracking of many biobehavioral and comorbid health outcomes over time. By systematizing standard metrics, measurement-based care is expected to improve assessment and facilitate adjustments in treatment to match the response of individual patients to care; improved quality and consistency of measurement will enhance the quality of care and the patient’s satisfaction with it, increase the health of the population, and probably reduce the per capita cost of care, the so-called triple aim of the Institute for Health Improvement.
A collaborative care chronic illness process for chronic pain would need assessment measures for the specific chronic pain domains frequently encountered in patients with complex chronic pain. This model would require formulating an individualized stepped care plan that matches a patient’s unique combination of active co-occurring disorders with the interspecialty domains of chronic pain. Measurement-based stepped care would systematically identify multidimensional signs and symptoms of poor physical, emotional, and sleep function and longitudinally track treatment outcomes across these specific domains. Structured multidimensional pain measurement and consistent tracking of treatment outcomes are needed to reliably and routinely prompt modifications in any care provided.
At the University of Washington, chronic pain is currently being measured with a number of specific evidence-based public domain tools. These measures are recorded in an electronic database, which can individually report the patient’s status at each visit, starting with the initial identification of chronic noncancer pain (advised to begin at day 90 of opioid therapy) and at all subsequent pain treatment follow-up visits. Different tracking versions are in place that range from pain specialty consultation to primary care practice. Unique modules are being developed for specialties commonly encountering challenges in pain management, such as orthopedics, physical medicine and rehabilitation, rheumatology, and neurology.
Problem of Noncollaborative Pain Care
Many challenges confront chronic pain care as a result of gaps in policy, treatments, attitudes, education, and research, as detailed in the 2011 report Relieving Pain in America by the IOM. Not only does the IOM fundamentally identify pain management as a moral imperative, but it also outlines the importance of comprehensive treatment, the need for interdisciplinary approaches, the importance of prevention, wider use of existing knowledge, recognition of the conundrum of opioid use, collaborative roles for patients and clinicians, and the value of a public health– and community-based approach.
Pain care also suffers from the frustratingly limited ability of most current chronic pain treatments, either interventional or noninterventional, to reduce the intensity of pain , with efficacy typically being less than 30%. These therapeutic limitations redirect attention to what else beyond pain intensity predicts success or failure in managing chronic illness. Stepped care is such a structured process for assessing and reducing the adverse impact of chronic pain on additional life measures—less of “how much does it hurt?” and more about physical function, mood, quality of life, and access to systematic care.
Current models of delivery of pain care tend to be noncollaborative , fragmented, and inconsistent. A struggling primary care provider unable to identify the cause of a patient’s disabling, severe persistent pain may recognize that the patient is doing poorly despite escalating doses of opioids without improvement in pain or function and with high levels of patient distress and problems in adherence and compliance. Referral to a wide range of specialists should follow, but to which specialist, triggered by what measures, and with what goal? Figure 4.4 illustrates the status quo in today’s common treatment approach to chronic pain. Common issues, questions, and potential problems that arise from such an inadequate model of care include the following:
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How and when does the primary care provider determine which specialist to refer to?
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How likely is it that the recommendations will be coordinated with other members of the care team?
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Are all specialists in agreement about what to measure to meet the diagnosis and treatment goals?
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Can all agree on which care guideline to use?
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How does the patient make sense of all this advice and move forward into a meaningful treatment plan?
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Who is measuring compliance and adherence to whatever treatment plan is chosen?
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Are records shared?
Given the inadequacies of current practice in the management of chronic pain, discussion of the stepped care approach provides some context toward a more collaborative and integrated management of care for patients with chronic pain.
Steps 1 and 2: Measuring Pain Intensity and Pain Interference
Von Korff and others developed and validated a two-item pain intensity and interference scale that has been endorsed by the Washington State Agency Medical Diretors Group (AMDG) guideline ( Fig. 4.5 ). It is specifically intended for use by primary care prescribers of opioids, with the goal of assessing response to opioid treatment when given for the management of chronic pain of noncancer origin.
Other validated but more detailed tools to measure how much pain interferes with function have been used for decades, especially the Oswestry and the Roland-Morris Disability Questionnaires. These measures provide a more detailed assessment and identify specific activities of daily living directly affected by chronic pain.
Step 3: Assessment of Mood and Risk Factors
Screening for Depression and Anxiety
Given the biopsychosocial impact of chronic pain, it is imperative that the impact of chronic pain on mood be measured consistently. Many studies have documented the utility of specific measures to assess and address depression, in particular, the PHQ-9 ( Fig. 4.6 ). Pain with co-occurring psychological disorders managed in 14 rural primary care practices demonstrated improved outcomes when longitudinally measured with the Medical Outcomes Study Short-Form 36-Item (SF-36) survey and the Functional Interference Estimate at baseline, 6 months, and 12 months.
Measuring the mood of chronic pain patients at every clinical encounter is as reasonable as measuring blood pressure and weight in addition to pulse when evaluating cardiac status. Direct observation has shown that the time needed for patients to complete the nine-item PHQ-9 paper form is just 15 to 30 seconds (personal observations by D.T.). Clinicians may also adopt a shorter version for assessment of mood in place of the PHQ-9. For example, the PHQ-4 is a validated shortened combination of two measures from the PHQ-9 depression questionnaire and two measures from the Generalized Anxiety Disorder 7-item scale (GAD-7) anxiety questionnaire ( Fig. 4-7 ). In addition, the publicly available item banks of the Patient-Reported Outcomes Measurement Information System (PROMIS) developed by the National Institutes of Health include well-developed mood and other pain-related affective disorder assessments that deploy computer adaptive testing technology to provide the shortest selection of questionnaire items needed to reliably assess the domains of interest. Other tools to measure mood are also widely available, and although the diversity of instruments will stimulate research in psychometrics, the use of diverse questionnaires in clinical effectiveness research inhibits direct comparisons between outcomes from different study populations. Therefore, a move toward the selection of standard measures holds much promise in the development and continuing advancement of the PROMIS item banks.
